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REFERRAL FORM West Hampshire MSK service UPPER LIMB Lymington New Forest Hospital Wellworthy Road Hants SO41 8QD Tel: 0845 0509 503 Age 16 + service only Forename: «PATIENT_Forename1» Surname: «PATIENT_Surname» Address: «PATIENT_BlockAddress» Patient consent to leave a message? Home No: «PATIENT_Main_Comm_No» Work No: «PATIENT_Alt_Comm_No» Mobile No: «PATIENT_Mobile_No» When is the best time to call? Email: The service strives to contact patients as quickly as possible. Please help us by providing as many contact details as possible. Urgent Non-Urgent Shoulder Elbow Wrist/hand DIRECT CONSULTANT OPINION REQUESTED Sex: «PATIENT_Sex» DoB: «PATIENT_Date_of_Birth» NHS no: «PATIENT_Current_NHS_Nu mber» UBRN No: «REFERRAL_UBRN» Hospital No: «REFERRAL_Hospital_numbe r» Previous Name: «PATIENT_Previous_Surnam e» Occupation: Registered GP: «PATIENT_Registered_GP» Referring GP: «REFERRAL_Clinician» Surgery address: «PRACTICE_BlockAddress» E-mail: Phone: «PRACTICE_Main_Comm_No» Fax: «PRACTICE_Fax_No» Date of Referral: «SYSTEM_Date» Signs/Symptoms: (Including any red flags, malignancies, specific diagnostic features, investigations and any patient requests) Functional disability: Effect on sleep: Provisional diagnosis: Current BP (latest): «PATIENT_BP» (if reading not in last 6 months, please retake): Current BMI (latest): «PATIENT_BMI» (if reading not in last 6 months, please retake): Previous orthopaedic/rheumatology referrals: Previous treatment for upper limb pain Physiotherapy: Surgical: Rheumatology: Pain clinic: Podiatry: Yes No Where: Why: Current treatment for upper limb pain (including medication used to date) Test Results: (please attach) X ray/scans: what: Where: Blood tests: (if relevant) Full blood count Erythrocyte sedimentation rate Plasma c reactive protein Prostate specific antigen Other blood tests Expectation of referral (GP and Patient): Additional info, e.g. Practitioner safety, specific needs etc…: Summary of Patient’s Record: Family History Problems «PROBLEMS» Repeat Medication «REPEATS» Allergies «DRUG_ALLERGY»